Tehama County Department of Social Servic COUNTY OF TEHAMA

P.O. BOX 1515

RED BLUFF, CA 96080
Date: 12/26/2023
Case Name: RYAN LYNCH
Case Number: 2042705
INSTRUCTIONS AND PENALTIES Worker Name: Intake Red Bluff
SAR 7 ELIGIBILITY STATUS REPORT Worker ID: 52LS02E40A
For Cash Aid and CalFresh Worker Phone Number: (530) 528-4114

RYAN P LYNCH
14530 WARREN AVE
RED BLUFF, CA 96080-9474

Need Help? Call the County.

If you do not send in a complete report including, but not limited to, answering all questions on the SAR 7 and attaching
proof when we ask for it, your benefits may be delayed, changed, or stopped. Attach a separate sheet of paper if needed.
Facts you report may result in your benefits going up, down, or being stopped.
Send in your completed report by the 5th of the month after the report month. It is late after the 11th.
Examples
Income Wages Self-Employment Salary
Vacation pay Tips Income In-kind, such as earned housing, free
In-Home Supportive Interest or dividends housing/utilities/clothing/food
Services (IHSS) Strike benefits Gambling/Lottery winnings
Child/spousal support Tax refunds Cash, gifts, loans, scholarships
Insurance or legal Unemployment Other private or government disability or
settlements Social Security retirement
Rental income and rental Supplemental Security Workers Compensation
assistance Income/State Veterans or Railroad retirement
Any government benefits Supplementary Payment
State Disability Indemnity (SSI/SSP)

Property Motor vehicles Checking Savings

EBT cash aid balance Saving Bonds Life Insurance policies
Home Land Trusts
Housing Rent Mortgage Property taxes
Costs Utilities Homeowners insurance Garbage/trash collection fees
Expenses Medical expenses College tuition & supplies Transportation
Health insurance premiums Mandatory school fees Room & Board
Child/dependent Care Child/spousal support Housing costs
Gross income means the amount you get before deductions are taken out (Examples of deductions are: Taxes, Social Security or other
retirement contributions, health care plan premiums, garnishments, etc.).
Penalties
PENALTIES FOR CASH AID FRAUD: If on purpose you do not PENALTIES FOR CALFRESH FRAUD: If on purpose you do
follow Cash Aid rules, your Cash Aid can be lowered for a not follow CalFresh rules, your CalFresh benefits can be
period of time and you may be fined up to $10,000 and/or sent stopped for 12 months for the first violation, 24 months for
to jail or prison for up to 3 years. the second, and forever for the third. You may be fined up
Your Cash Aid can be stopped: to $250,000 and/or sent to jail/prison for 20 years.
If you are found guilty in any court of law or administrative
For not reporting all facts or for giving wrong facts: 6 months
hearing because:
for the first offense, 12 months for the second offense, or
forever for the third. You traded or sold CalFresh benefits for firearms,
ammunition, or explosives, your CalFresh benefits can be
For submitting one or more applications to get aid in more than one
stopped forever for the first violation.
case for the same time period: 2 years for the first conviction,
4 years for the second, and forever for the third. You traded or sold CalFresh benefits for controlled
For conviction of felony fraud to get aid: 2 years for theft of amounts substances, your CalFresh benefits can be stopped for 24
under $2,000; 5 years for amounts of $2,000 through $4,999.99; months for the first violation and forever for the second.
and forever for amounts of $5,000 or more. You traded or sold CalFresh benefits that were worth $500
Forever: for giving the county false proof of residency in order to get aid or more, your CalFresh benefits can be stopped forever.
in two or more counties or states at the same time; giving the county You gave the county false identify or residence
wrong facts for an ineligible child or a child that does not exist; information, so you can get CalFresh benefits in more than
getting more than $10,000 in cash benefits through fraud; getting a one case at the same time, your CalFresh benefits can be
third conviction for fraud in a court of law or an administrative hearing. stopped for 10 years.

SAR 7 ADDENDUM (4/13) ELIGIBILITY STATUS REPORT - SEMI-ANNUAL FOR CASH AID AND CALFRESH - REQUIRED FORM - SUBSTITUTES PERMITTED

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REPORTING CHANGES FOR CASH AID

AND CALFRESH
Date Issued:
12/26/2023
Case Name:
RYAN LYNCH
Case Number:
2042705
Worker Number:
(530) 528-4114

Because you get Cash Aid CalFresh, you must report within 10 days when your TOTAL income reaches a
certain level. You must report anytime your household’s total monthly income is more than your current Income Reporting
Threshold (IRT).

Benefit Type CalWORKs CalFresh

Family Size N/A 1
Effective Month: 01/2024
Your Current Income N/A $0.00
Your IRT is N/A $1,580.00

Note: If your IRT for CalFresh is listed as "N/A", you are not required to report income changes for CalFresh until your next
SAR 7 or recertification whichever comes first. However, if you have an IRT amount listed for CalWORKs, you must
report when your gross income goes over that amount.

How to report?
If your total income is over the IRT amount listed above, you must report this to the County within 10 days. You can report
this information to the County by calling the county or reporting it in writing.

By “total monthly income” we mean:

➯ Any money you get (both earned and unearned).
➯ The amount before any deductions are taken out. (Examples of deductions are: taxes, Social Security or other
retirement contributions, garnishments, etc.)

What will happen?

➯ Your benefits may be lowered or stopped based on income over your IRT.
➯ Your IRT may change when your income changes or when someone moves in or out of your home.

➯ The County will let you know in writing each time your IRT changes.

➯ You also need to report on your SAR 7 all income you get during the Report Month, even if you already reported that
money.

SAR 2 (6/19) Required Form - Substitutes Permitted

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Penalty for not reporting

If you do not report when your income is more than your household’s IRT limit you might get more benefits than you should. You
must repay any extra benefits you get. If you do not report on purpose to try to get more benefits, this is fraud, and you may be
charged with a crime and/or may no longer get CalFresh for a period of time or life.

If you get Cash Aid, you MUST ALSO report the things below within 10 days of when they happen:

1. Anytime someone joins, or is in your household, who has been found by a court of law to be in violation of a condition of
probation or parole.

2. Anytime someone joins, or is in your household, who is running from the law (has a warrant out for their arrest.)

3. Anytime you have an address change.

If you get CalFresh, you MUST ALSO report the following:

• If you are an Able Bodied Adult Without Dependents (ABAWD), you must report anytime your work or training hours
drop to less than 20 hours a week or 80 hours a month.

Voluntarily reporting information

You may also voluntarily report changes to the County anytime. Reporting some changes may get you more benefits. For
example:

• Your income stops or goes down.

• Someone with income moves out of your home.

• Someone without income moves into your home.

• Someone in the house becomes pregnant.
• Someone on cash aid has a special need, such as: a pregnancy, a special diet prescribed by a doctor, household
emergency, etc.
• The birth of a child.
• For CalFresh, if someone disabled or age 60 or older has new or higher out of pocket medical costs.

Note: Some changes you report voluntarily may result in a decrease in your CalFresh benefits.

For this form in large print or another format, please call your county.

SAR 2 (6/19) Required Form - Substitutes Permitted

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES

SAR 7 ELIGIBILITY STATUS REPORT COUNTY OF TEHAMA

Date: 12/26/2023
Case Name: RYAN LYNCH
Case Number: 2042705
Worker Name: Intake Red Bluff
Worker ID: 52LS02E40A
FIRST-CLASS MAIL PERMIT NO. 3 RED BLUFF CA
POSTAGE WILL BE PAID BY ADDRESSEE Worker Phone Number: (530) 528-4114

TEHAMA CO SOCIAL SERVICES

PO BOX 1515
RED BLUFF, CA 96080-9906

REPORT MONTH December

TO KEEP YOUR BENEFITS COMING ON TIME, PLEASE SIGN THE FORM AFTER January 1ST AND RETURN IT BY January 5TH
SUBMIT MONTH SUBMIT MONTH

Check the box if you would like to STOP getting any of the following: STOP my CalWORKs STOP my CalFresh
STOP my Medi-Cal
1. Has anyone moved into or out of your home (including newborns) or did you move in with someone else since you last
reported? p Yes p No (If yes, complete the section below).
Date of Move Name Relationship To Regularly Purchase And
Date Of Birth
(mm/dd/yy) (First, Middle, Last) You Prepare Food Together?
In Out / / / / YES NO
In Out / / / / YES NO
In Out / / / / YES NO
2. Have there been any changes to your address since you last reported? Yes No (If yes, complete the section below.)
New Address: __________________________________________________________________ Date Moved: ___________________________
Mailing Address (if different than above) ____________________________________________________________________________
3. If you have moved since you last reported please fill out the section below:
Your rent or mortgage per month now? If paid separately, your property taxes and home insurance per month now?
$ $
Do you have utility costs that are not included in your rent or mortgage payment? If so, check which ones:
Phone Trash Water Electric/Gas Other heating or cooling costs
4. CalWORKs only: Is anyone in your home:
A. Running from an outstanding warrant?
B. Found by a court to be in violation of probation or parole? Yes No (If yes, complete the section below.)
Name of person A or B In what state was the warrant issued, Date of warrant or
from above or did violation happen? violation

5. Medical Costs: If anyone who gets CalFresh and is 60 years old or older, or disabled, had an increase in medical costs please
complete the section below and attach proof:
Who had the change? Amount of increase:
$
6. Child Support: Did anyone who gets CalFresh have a change in the amount of child support they have to pay since they last
reported? Yes No If yes, complete the section below and attach proof.
What was the amount paid in the Report Month? $ __________. Who paid support? _______________________________________________
7. Dependent Care: If anyone who gets CalFresh and either works, is looking for work , or is going to school, had an increase
in out-of-pocket dependent care costs since they last reported, please complete the section below and attach proof:
What was the amount paid out-of-pocket in the Report Month? $ __________
Who paid: _________________________________ List dependent(s): _________________________________________________
8. Did anyone: Get, buy, sell, trade or give away any property, land, homes, cars, bank accounts, money, payments (such as
lottery/casino winnings, back benefits from social security), or other property items since last reported?
Yes No (If yes, complete the section below and attach proof. If you need more space, attach a separate piece of paper.)
Who? Type of Property? When? Amount/Value? Bought Sold Gave Away Spent
Got as a gift Traded Won Other
SAR 7 (12/14) ELIGIBILITY STATUS REPORT - FOR CASH AID AND CALFRESH - REQUIRED FORM - SUBSTITUTES PERMITTED

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9. Did anyone get income from employment in the Report Month? Yes No (If yes, complete the section below and attach proof.) The
Report Month is listed at the top of the first page. List each job for each person who works. If you need more space attach a separate piece of
paper. Examples include babysitting, salary, self-employment, sick pay, tips, etc. If you lost your job, attach proof.
Job #1 Job #2 Job #3
Name of person who got income:

Source of income/Employer name:

Self-employed, check here Self-employed, check here Self-employed, check here
Weekly Biweekly Other Weekly Biweekly Other Weekly Biweekly Other
How often paid:
Monthly Twice monthly Monthly Twice monthly Monthly Twice monthly

Gross amount of income they got in the $ $ $

DATE(S) RECEIVED: DATE(S) RECEIVED: DATE(S) RECEIVED:
report month:

Hours worked per month:

10. Will there be any changes to your income from employment in the next six months (including income listed in #9)? Yes No
(If yes, explain here and attach proof). Examples: Stopping or starting a job; increase or decrease of income; changes in hours; quitting a job
or going on strike; change in how often you are paid.

11. Did anyone get money from any other source in the Report Month: Yes No (If yes, complete the section below and attach proof.)
The Report Month is listed at the top of the first page. Examples include: Social Security, Unemployment Compensation, Veterans Benefits, State
Disability Insurance (SDI), Child/Spousal Support, Worker’s Compensation, Loans/Gifts, Earned/Unearned Housing, Utilities, Food, etc. If you no
longer get money from a source you previously reported, attach proof.
Name Source of income One time payment or monthly How much
$
$
$
12. Will there be any changes to money received from any other source in the next six months (including income listed in #11)?
Yes No (If yes, explain here and attach proof.) Examples of changes: An increase or decrease in income or benefits, or if you will
start or stop getting income or benefits.
13. CalWORKs only: Have any of the following happened to anyone in your home since you last reported? Yes No
(If yes, check below and attach proof):
Family Change (Married, divorced, separated, entered into a California Registered Domestic Partnership (RDP), have a non-California
Domestic Partnership (DP), ended a DP or RDP, became pregnant, or is no longer pregnant?)
Job/Employment (Start, stop, quit a job, started a business or went on strike?)
Disability (Became disabled or recovered from a disability or major illness?)
Immigration (Citizenship or immigration status change, or got a new card, form, or letter from USCIS (INS)?)
Insurance (Started, stopped, or changed health, dental, or life insurance benefits, including MEDICARE?)
Custody (Any change in the amount of time you care for/have custody of your children?)
In-Home Support Services (Started or stopped getting services?)
School Attendance
For Age 18 or older student - started or stopped school/college? (You may be able to claim costs for books, school transportation, etc.)
Someone paid for all of my housing, food, clothing or utility costs (please explain).
Other
Please read carefully, sign, and date.
By signing this form:
• I understand and certify, under penalty of perjury, that all my answers on this report are correct and complete to the best of my knowledge.
• I understand the penalties for fraud are as follows: I may be sent to prison for up to 20 years and fined up to $250,000. I may have to pay back
benefits if I was not eligible to them. The first time I break the rules on purpose I will not be able to get CalFresh for one year; the second time
two years; and after the third time I will not be able to get CalFresh again.
• I understand and agree to give copies of all documents needed to complete my semi-annual report.
• I understand that in some instances, I may be asked to give consent to the County to make whatever contacts are necessary to determine
eligibility.
CERTIFICATION - FRAUD WARNING
I UNDERSTAND THAT: If on purpose I do not report all facts or give wrong facts about my income, property, or family status to get or keep getting aid
or benefits, I can be legally prosecuted. I may also be charged with committing a felony if more than $950 in Cash Aid, and/or CalFresh is wrongly paid
out as a result of such an action. I have received a copy of the Instructions and Penalties for the SAR 7 Eligibility Status Report for Cash Aid and
CalFresh.
YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE REPORT MONTH OR IT WILL BE CONSIDERED INCOMPLETE.
I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this report are true and
correct and complete.
WHO MUST For Cash Aid: You and your aided spouse, registered domestic partner, or the other parent (of cash-aided children) if living in the home.
SIGN BELOW: For CalFresh: The head of household, a responsible household member, or the household's authorized representative.
SIGNATURE OR MARK DATE SIGNED HOME PHONE CONTACT/CELL PHONE

☛
SIGNATURE OF SPOUSE, REGISTERED DOMESTIC PARTNER, OR OTHER DATE SIGNED
( ) ( )
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR OTHER PERSON DATE SIGNED

☛ ☛
PARENT OF CASH AIDED CHILD(REN) COMPLETING FORM

SAR 7 (12/14) ELIGIBILITY STATUS REPORT - FOR CASH AID AND CALFRESH - REQUIRED FORM - SUBSTITUTES PERMITTED

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